Provider Demographics
NPI:1275594228
Name:LIPE, MARK GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:GREGORY
Last Name:LIPE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:SUITE 121
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-751-4664
Mailing Address - Fax:405-749-4561
Practice Address - Street 1:4300 W MEMORIAL RD
Practice Address - Street 2:ER DEPT.
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8304
Practice Address - Country:US
Practice Address - Phone:405-752-3733
Practice Address - Fax:405-749-4561
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16509207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK930046554OtherRR MEDICARE
OK100101520AMedicaid
OKP00046981OtherRR MEDICARE
OK100101520BMedicaid
OK930126936OtherRR MEDICARE
OK100101520BMedicaid
OK100101520AMedicaid
OK244234510Medicare ID - Type Unspecified